Treatment Protocol Dictionary¶

Reference for readers of the TEV (Talipes Equinovarus) dossiers. This dictionary defines every treatment, procedure, diagnostic tool, and intervention referenced in the TEV medical, patient, and general dossiers. It is written to be accessible to patient advocates, families, and non-clinical readers.

⚠️ This is research synthesis, NOT medical advice. All treatment decisions must be made with qualified healthcare providers in consultation with the patient.

1. Surgical Procedures¶

Triple Arthrodesis — Surgical fusion of three joints in the hindfoot: the talonavicular, calcaneocuboid, and subtalar joints. The bones are held together with screws or plates until they grow into a single solid bone. This eliminates painful motion in a deformed foot while preserving some ankle movement. It is the most common salvage procedure for adult post-clubfoot deformity. Reported satisfaction rates range from 81–100%, but these figures reflect pain relief and should be interpreted alongside the permanent trade-offs: complete loss of hindfoot motion, altered gait mechanics, and increased mechanical stress on the remaining ankle joint. 44–72% of patients develop ankle arthritis within 8 years, and some may eventually require ankle fusion or replacement. Recovery typically takes 3–6 months non-weight-bearing. Google Scholar: triple arthrodesis long-term outco
Ankle Arthrodesis (Ankle Fusion) — Surgical fusion of the ankle joint (tibiotalar joint), permanently eliminating all ankle motion. Used when the ankle joint is severely damaged by arthritis or deformity. The foot is locked at a functional angle (typically 5° of dorsiflexion). Patients can walk but lose the ability to flex the ankle, which changes gait mechanics. Modern percutaneous/arthroscopic techniques reduce surgical trauma. Often combined with triple arthrodesis when both hindfoot and ankle are involved. Wikipedia: ankle fusion procedure and indications
Total Ankle Arthroplasty (TAA) — An artificial ankle joint replacement, similar in concept to a hip or knee replacement. A metal and plastic implant replaces the damaged joint surfaces, preserving ankle motion unlike fusion. In post-clubfoot patients, TAA is considered only when soft tissue coverage is adequate (which is often not the case after childhood PMR surgery). The Fijany protocol specifically addresses TAA candidacy in complex post-surgical feet. Younger, active patients may benefit most, but implant longevity remains a concern — modern third-generation implants report 5-year survival >90% and 10-year survival ~80–89%, though long-term data are still maturing. Wikipedia: total ankle replacement overview
Taylor Spatial Frame (TSF) — An external fixator (metal frame attached to the bone through the skin with pins and wires) that uses computer-controlled struts to gradually correct complex 3D deformities. The frame stays on the leg for weeks to months while being adjusted daily via a prescription program. For post-clubfoot patients with severe multi-planar deformity, TSF can correct what a single surgery cannot. Reported success rates for deformity correction are generally high (80–90% in published series), though outcomes vary by deformity complexity and patient selection. Drawbacks include pin tract infections (reported in 10–50% of cases in the broader literature; specific clubfoot series report 19–27%), recurrence of deformity, and some patients may ultimately require arthrodesis. Patient compliance with daily adjustments is critical. Wikipedia: Taylor Spatial Frame device description
Ilizarov Technique — A circular external fixator system (predecessor to TSF) that uses the principle of distraction osteogenesis — slowly pulling bone apart so new bone grows in the gap. Used for limb lengthening, deformity correction, and nonunion treatment. The Ilizarov method is particularly valuable for relapsed clubfoot in children (age <8–10) and for adults with bone loss or non-healing fractures. Similar to TSF in concept but with different frame geometry and adjustment mechanisms. Wikipedia: Ilizarov apparatus and distraction oste
Osteotomy — Surgical cutting of a bone to realign it. Several types are used in post-clubfoot reconstruction: Wikipedia osteotomy article
Calcaneal osteotomy — cutting the heel bone to correct heel position (varus or valgus alignment)
Metatarsal osteotomy — cutting bones in the forefoot to correct pressure distribution
Medial column osteotomy — addressing the inner foot arch Osteotomies preserve joint motion (unlike fusion) and are preferred in younger patients with flexible deformity.
Tendon Transfer (ATT / TATT) — Surgically rerouting a tendon from one attachment point to another to restore muscle balance in the foot. In post-clubfoot reconstruction, the most common transfers include: Tibialis Posterior Tendon Transfer — moving the posterior tibial tendon (which pulls the foot inward) to the lateral cuneiform or dorsum of the foot to correct dynamic supination and intoeing; and Anterior Tibial Tendon (ATT) Transfer — splitting or fully transferring the tibialis anterior to the lateral cuneiform to rebalance dorsiflexion forces. TATT (Tibialis Anterior Tendon Transfer) refers specifically to the anterior tibial tendon transfer procedure. Tendon transfers are often combined with osteotomies for comprehensive correction. Wikipedia: tibialis posterior tendon transfer
Below-Knee Amputation (BKA) — Surgical removal of the leg below the knee. In post-clubfoot patients, BKA is considered when: vascular status prevents reconstruction (ABI <0.4), osteomyelitis is extensive (especially hindfoot), multiple salvage attempts have failed over 12+ months, or the patient prefers a definitive solution. The LEAP study (MacKenzie et al., NEJM 2005) found that at 2-year and 7-year follow-up, functional outcomes were similar between patients who underwent amputation and those who had limb reconstruction — suggesting that delayed amputation after failed salvage does not necessarily lead to worse outcomes than primary amputation, but the recovery journey is longer. Modern prosthetics are highly functional, though energy cost of walking increases 25–40%. Wikipedia: prosthetics and energy cost data
Free Flap Reconstruction — Transplanting tissue (skin, muscle, and blood vessels) from one part of the body (usually the thigh or back) to the foot to cover exposed bone, tendon, or hardware. The blood vessels are reconnected under a microscope. Used when the foot's soft tissue envelope is too damaged for direct wound closure — common in post-PMR feet with extensive scarring. Requires a skilled plastic/reconstructive surgeon and adequate recipient blood vessels.
Minimally Invasive Surgery (MIS) — Surgical techniques using small incisions, cameras, and specialized instruments. For post-clubfoot patients, MIS approaches include arthroscopic ankle fusion, percutaneous osteotomies, and endoscopic nerve decompression. Benefits: smaller scars, less soft tissue disruption, faster recovery. Limitations: may not be possible in severely scarred or deformed feet. StatPearls general orthopedic MIS reference

2. Wound Care Treatments¶

Total Contact Casting (TCC) — A specially applied fiberglass cast that distributes pressure evenly across the entire foot and lower leg, eliminating pressure points that cause or perpetuate wounds. TCC is the gold standard for offloading plantar (bottom-of-foot) ulcers and is considered the most effective wound healing intervention for structural deformity-driven wounds. The cast is typically changed every 1–2 weeks for wound assessment, per IWGDF guidelines. In post-clubfoot patients, TCC must be custom-contoured to accommodate the deformed foot anatomy. Wikipedia: TCC as gold standard for DFU offloading
Negative Pressure Wound Therapy (NPWT / VAC) — A wound dressing system that applies controlled suction (negative pressure) to the wound through a sealed foam sponge connected to a portable pump. The suction removes excess fluid, reduces swelling, increases blood flow, and promotes granulation tissue (new healing tissue) growth. Dressing changes are typically performed 2–3 times per week; therapy may be continuous or intermittent depending on the clinical protocol. Particularly effective for deep or cavity wounds that can't heal from the surface alone. Requires adequate blood supply to work. Wikipedia: NPWT/VAC description and protocols
Hyperbaric Oxygen Therapy (HBOT) — Breathing 100% oxygen in a pressurized chamber (typically 2–2.5 atmospheres) for 60–90 minutes per session, 5 days per week for 4–6 weeks. The increased pressure drives oxygen into the blood and wound tissues at concentrations impossible under normal conditions. This promotes new blood vessel formation, fights infection, and accelerates healing. Indicated when TcPO2 (transcutaneous oxygen) at the wound margin is <30 mmHg. Insurance coverage varies; typically requires documented wound failure with standard care first. Wikipedia: hyperbaric oxygen therapy overview
Platelet-Rich Plasma (PRP) — A concentration of the patient's own blood platelets, prepared by drawing blood and spinning it in a centrifuge. Platelets contain growth factors that promote healing. PRP is injected into or applied to chronic wounds that haven't responded to standard care. Being autologous (from the patient's own body), there is no rejection risk. Evidence is moderate — PRP can accelerate healing in recalcitrant wounds but is not a standalone treatment. Typically added at 2 weeks if standard offloading and wound care haven't produced improvement. Wikipedia PRP article
Bioengineered Skin Substitutes — Lab-grown living skin tissue products used to cover chronic wounds and stimulate healing: DailyMed: FDA drug and biologic labeling
Apligraf — a bilayer product containing living human skin cells (keratinocytes and fibroblasts) on a bovine collagen matrix. Applied as a dressing that provides growth factors and a scaffold for new tissue growth.
Dermagraft — a cryopreserved human fibroblast-derived dermal substitute. Provides a living dermal layer that promotes wound closure. These are used when wounds stall at 8 weeks despite optimal offloading and standard care. They are expensive ( $1,000–$ 3,000 per application) and may need multiple applications.
REGRANEX (Becaplermin) — A topical gel containing recombinant human platelet-derived growth factor (PDGF-BB), applied daily to chronic wounds. It stimulates cell growth and tissue repair. FDA-approved for diabetic neuropathic foot ulcers; used off-label for non-diabetic structural wounds. The gel is applied in a thin layer to the wound bed and covered with a saline-moistened dressing. Typically used after wound debridement. Note: The FDA issued a Public Health Advisory (2008) regarding increased cancer mortality observed with three or more tubes in an observational study. Cancer risk is listed as a precaution in current labeling (Section 5.1). Discuss risk-benefit with your physician. DailyMed: REGRANEX (becaplermin) FDA labeling
TOT (Topical Oxygen Therapy) / NATROX — A portable device (NATROX®) that delivers pure oxygen directly to the wound surface through a small, battery-powered generator and a silicone delivery pad placed over the wound. Unlike HBOT, it doesn't require a chamber and can be used continuously at home. Evidence is emerging for chronic wounds, particularly in patients who can't access HBOT. Less effective than systemic HBOT for deep tissue hypoxia.
Sharp/Surgical Debridement — The removal of dead, damaged, or infected tissue from a wound using surgical instruments (scalpel, curette, or scissors). This is the standard first step in wound management — a wound cannot heal if it's covered with necrotic tissue. In post-clubfoot patients, debridement may need to be repeated regularly because the structural deformity continually recreates pressure points and tissue damage. Performed under local anesthesia in an outpatient setting. Wikipedia debridement article
Adipose-Derived Stem Cell Therapy (ADSC) — Harvesting fat tissue from the patient (usually abdomen or thigh via liposuction), processing it to concentrate stem cells and regenerative factors, and injecting the concentrate into chronic wounds or surgical sites. The stem cells may promote new blood vessel formation and tissue repair. Currently considered experimental/investigational for chronic foot wounds. Access is primarily through clinical trials or research institutions. PubMed review on adipose-derived stem cells

3. Diagnostic Tools¶

ABI (Ankle-Brachial Index) — A simple, non-invasive test comparing blood pressure at the ankle to blood pressure in the arm. A normal ABI is 0.9–1.3. Values of 0.4–0.9 indicate peripheral arterial disease of increasing severity; below 0.4 indicates critical limb ischemia (severely reduced blood flow). This is the single most important screening test before any foot surgery or wound treatment — surgery cannot heal wounds if blood supply is inadequate. ABI >0.7 is generally required for reconstruction candidacy. Wikipedia: ABI interpretation and PAD grading
TBI (Toe-Brachial Index) — Similar to ABI but measures blood pressure at the toe instead of the ankle. More accurate than ABI in patients with calcified arteries (common in diabetes and advanced vascular disease), because toe arteries are less likely to be calcified. Normal TBI is >0.7. Used alongside ABI for a complete vascular picture. PubMed TBI vascular assessment guidelines
TcPO2 (Transcutaneous Oxygen Tension) — A measurement of oxygen levels in the skin at the wound margin using a small heated electrode placed on the skin. Values above 30 mmHg generally indicate adequate oxygen for wound healing; below 30 mmHg suggests the wound is unlikely to heal without intervention (revascularization or HBOT). This test directly measures what matters most for wound healing: is there enough oxygen reaching the tissue?
WIfI Classification (Wound, Ischemia, foot Infection) — A standardized staging system that grades three factors: wound severity (0–3), ischemia (0–3), and foot infection (0–3). The combined score predicts two things: (1) the risk of amputation at one year, and (2) the likelihood that revascularization will help. Developed by the Society for Vascular Surgery (Mills JL Sr et al., J Vasc Surg 2014). WIfI staging guides treatment decisions: a patient with high ischemia and low infection may benefit most from revascularization, while one with low ischemia but high infection needs antibiotics and debridement first.
Pedobarography (Plantar Pressure Mapping) — A technology that measures the pressure distribution on the sole of the foot during standing and walking. The patient walks over a pressure-sensitive mat or insoles that create a color-coded map showing high-pressure areas. In post-clubfoot patients, this identifies exactly where the foot is bearing excessive load — which directly predicts where wounds will form or recur. Used to design custom orthotics and footwear that redistribute pressure away from vulnerable areas.
NCS/EMG (Nerve Conduction Studies / Electromyography) — Two complementary tests that assess nerve and muscle function. NCS measures how fast electrical signals travel through nerves (slowing indicates nerve damage). EMG measures the electrical activity of muscles at rest and during contraction (abnormal patterns indicate denervation or muscle damage). In post-clubfoot patients, these tests identify tarsal tunnel syndrome (nerve compression at the ankle), peroneal nerve entrapment, and peripheral neuropathy — all of which may be caused or worsened by prior surgery.
CT with 3D Reconstruction — A computed tomography scan that creates detailed cross-sectional images of bone, which are then assembled into a 3D computer model. Essential for surgical planning in post-clubfoot patients because standard X-rays underestimate the complexity of 3D deformity. The 3D model allows the surgeon to plan osteotomy cuts, screw placement, and fusion angles before entering the operating room.
MRI (Magnetic Resonance Imaging) — Uses magnetic fields (not radiation) to create detailed images of soft tissues: tendons, ligaments, cartilage, bone marrow, and muscles. In post-clubfoot patients, MRI is used to assess: tendon integrity (especially the tibialis posterior), cartilage damage, bone marrow edema (early AVN), osteomyelitis (bone infection), and soft tissue scarring. MRI is the gold standard for detecting osteomyelitis when combined with clinical context. NIBIB/NIH definition of MRI
Duplex Ultrasound — A combination of traditional ultrasound (showing anatomy) and Doppler ultrasound (showing blood flow). Used to map the arteries of the leg from the groin to the foot, identifying blockages, narrowing, and the quality of blood flow through each vessel. This is a non-invasive alternative to angiography for initial vascular assessment and can identify which specific arteries are open or blocked — critical information for planning revascularization. NIH: Duplex ultrasound vascular assessment
3D Gait Analysis — A laboratory-based assessment using cameras, force plates, and markers placed on the body to create a detailed 3D model of how a person walks. Measures joint angles, forces, timing, and muscle activity during each step. In post-clubfoot patients, this identifies specific gait abnormalities (compensatory patterns, asymmetric loading, reduced ankle push-off) that guide rehabilitation and orthotic design. Wikipedia human gait article

4. Orthotics & Assistive Devices¶

AFO (Ankle-Foot Orthosis) — A brace extending from below the knee to the foot, controlling ankle and foot position during walking. Rigid AFOs completely prevent ankle motion (used post-fusion); articulated AFOs allow some controlled motion; dynamic AFOs (e.g., carbon fiber spring AFOs) store and return energy to assist push-off. In post-clubfoot patients, AFOs compensate for lost ankle motion, prevent foot drop, and reduce abnormal loading. Modern 3D-printed AFOs can be custom-shaped to accommodate deformed foot anatomy. StatPearls: Ankle-Foot Orthosis definition
Custom Orthoses — Shoe inserts individually manufactured from a mold or scan of the patient's feet. Unlike off-the-shelf insoles, custom orthoses are contoured to the specific deformity, redistributing pressure away from wound-prone areas and supporting collapsed arches. In post-clubfoot patients, orthoses must accommodate rigid deformity, scarring, and asymmetric anatomy. Typically made from rigid or semi-rigid materials with soft top covers. AOFAS: Custom orthotics for foot conditions
Therapeutic Footwear — Prescription shoes designed for patients with foot deformity and chronic wounds. Key features include: extra depth (to accommodate orthoses without creating new pressure points), rocker-bottom sole (to facilitate roll-over during gait despite stiff joints), adjustable closure systems (to accommodate wound dressings and swelling), and extra width. Two or more identical pairs should be rotated to allow wear leveling. Not the same as diabetic shoes — therapeutic footwear for structural deformity requires more customization.
Total Contact Boot / Removable Walker Boot — A removable alternative to TCC (total contact cast) for wound offloading. Less effective than a true TCC because the patient can remove it, but provides similar pressure redistribution when worn. Used as a bridge when TCC isn't immediately available, or for patients who need periodic wound inspection. The patient must be counseled: removing the boot to "check the wound" defeats the purpose of offloading.

5. Rehabilitation & Physical Therapy¶

NMES (Neuromuscular Electrical Stimulation) — Applying electrical current through surface electrodes on the skin to cause muscle contraction. Used to strengthen weak or denervated muscles that the patient can't voluntarily contract. In post-clubfoot patients, NMES targets the tibialis anterior (for foot drop), tibialis posterior (for arch support), and intrinsic foot muscles. A staged NMES-then-FES approach can produce substantial functional improvements in walking speed and endurance, though individual outcomes vary significantly depending on the degree of nerve damage and patient compliance. Wikipedia: FES/NMES clinical applications
FES (Functional Electrical Stimulation) — A form of NMES applied during functional activities (specifically walking). A sensor detects gait phases and triggers electrical stimulation to the common peroneal nerve at exactly the right moment during the walking cycle, causing the foot to lift during swing phase (correcting foot drop). Devices like WalkAide and L300 are commercially available. Studies show FES and AFOs produce equivalent improvements in walking speed for foot drop — FES may be preferred when AFO fitting is problematic due to foot deformity. Wikipedia: FES for foot drop and gait
TENS (Transcutaneous Electrical Nerve Stimulation) — A small, battery-powered device that delivers low-voltage electrical current through adhesive pads placed on the skin near the painful area. The stimulation is thought to "interfere" with pain signal transmission and stimulate endorphin release. Used for chronic neuropathic and musculoskeletal pain management. Moderate evidence for pain relief; no significant side effects. Can be used alongside medication and physical therapy.
Gait Retraining — A structured program where a physical therapist analyzes the patient's walking pattern and teaches corrective techniques. For post-clubfoot patients, common targets include: reducing compensatory hip hiking, improving push-off timing, normalizing stride length symmetry, and reducing excessive lateral weight shift. May use real-time feedback from mirrors, video, IMU sensors, or smartwatches. Requires 3+ sessions per week for 6–12 weeks minimum. Wikipedia human gait article
Exoskeleton-Assisted Gait Training — Wearable robotic devices (e.g., EksoNR, ReWalk) that support and guide leg movement during walking rehabilitation. The patient wears a powered frame that assists hip and knee motion while body weight is partially supported. Primarily developed for neurological rehabilitation (stroke, spinal cord injury), but emerging evidence for musculoskeletal applications. Typically available only at major rehabilitation centers. Cost: $50,000–$ 150,000+ for device purchase; $150–$ 400/session for clinical access. Wikipedia: ReWalk exoskeleton pricing and details
Robotics-Assisted Gait Training — Treadmill-based systems (e.g., Lokomat, G-EO System) that use robotic legs to guide the patient's gait pattern while body weight is partially supported by a harness. Allows high-repetition walking practice in a safe, controlled environment. More accessible than overground exoskeletons. Evidence: improved walking distance, gait symmetry, and endurance in various populations. Available at rehabilitation centers like UW Medicine and OHSU. Wikipedia human gait article

6. Vascular Interventions¶

Endovascular Angioplasty / Stenting — A minimally invasive procedure where a thin catheter is threaded through an artery (usually from the groin) to the blockage in the leg. A small balloon is inflated to compress the plaque against the artery wall, and a metal mesh stent may be placed to keep the artery open. Used for focal (short segment) arterial stenosis in patients with ABI <0.7 who need revascularization before foot surgery or wound healing. Recovery is quick (same-day or overnight), but stents can re-narrow over time. Wikipedia — angioplasty
Surgical Bypass — Creating a detour around a blocked artery using a vein graft (usually the patient's own saphenous vein) or synthetic graft. One end is connected to the artery above the blockage, the other to the artery below it, restoring blood flow to the foot. Used for long-segment arterial occlusions that can't be treated with angioplasty. More invasive than endovascular approaches but may be more durable for extensive disease. Requires adequate vein availability and surgical expertise. SVS: Bypass surgery for peripheral arterial disease
Sympathectomy — Surgical or chemical interruption of the sympathetic nerves that control blood vessel constriction in the leg. By blocking these nerves, the small arteries in the foot dilate (widen), improving blood flow and oxygen delivery to wounds. Can be performed surgically (open or laparoscopic) or chemically (injecting alcohol or phenol around the nerve). Used as an adjunct to revascularization or in patients who aren't candidates for bypass/angioplasty.

7. Pharmacological & Biological Therapies¶

Gabapentinoids (Gabapentin, Pregabalin) — Medications originally developed for seizures that are now first-line treatment for neuropathic (nerve) pain. They work by reducing abnormal nerve firing. In post-clubfoot patients, neuropathic pain is common due to nerve entrapment (tarsal tunnel) and surgical nerve damage. Gabapentin is typically started at low doses and titrated up over weeks. Side effects include drowsiness, dizziness, and peripheral edema. Pregabalin works similarly but has a more predictable absorption.
Growth Factor Therapy — Applying concentrated proteins (growth factors) that stimulate cell division and tissue repair directly to chronic wounds. Sources include autologous blood products (PRP), recombinant DNA products (REGRANEX/PDGF), and platelet lysate. The concept: chronic wounds are "stalled" in the healing process, and adding concentrated growth factors can restart the healing cascade. Evidence varies by product and wound type; PRP and REGRANEX have the most clinical data.
Gene Therapy for Wound Healing — An experimental approach where genetic material is introduced into wound cells to produce specific healing-promoting proteins. For example, the gene therapy product VM202 (developed by Helixmith, formerly ViroMed) delivers the gene for hepatocyte growth factor (HGF), causing the patient's own cells to produce HGF at the wound site. This promotes new blood vessel formation (angiogenesis) and tissue repair. Currently in clinical trials; not yet FDA-approved for chronic wounds.

8. Emerging & Investigational Therapies¶

PEP Exosomes (RION) — Exosomes are tiny vesicles (packages) released by cells that carry signaling molecules to other cells. RION Therapeutics develops exosome-based products derived from platelets (their primary investigational product is RION-001). These exosomes carry growth factors and anti-inflammatory signals that may promote wound healing without the variability of whole PRP. Access is through clinical trials or expanded access programs (riontx.com). Currently investigational — not FDA-approved.
3D-Printed Custom AFOs — Ankle-foot orthoses manufactured using 3D scanning of the patient's foot and 3D printing technology. This allows AFOs to be precisely contoured to the specific deformity, including accommodating surgical hardware, scarring, and asymmetric anatomy. Advantages over traditional fabrication: faster turnaround, perfect fit replication, easy modification. Comparative studies show equivalent or improved gait parameters versus traditional AFOs with better patient comfort. StatPearls: Ankle-Foot Orthosis definition
Wearable IMU Sensors for Gait Monitoring — Small inertial measurement units (containing accelerometers and gyroscopes) worn on the foot, ankle, or lower back that continuously track walking patterns. Modern IMU-based gait analysis systems use foot-mounted sensors (typically 6-axis, 50–200 Hz sampling) with machine learning algorithms to estimate stride length, cadence, and gait symmetry. For post-clubfoot patients, this enables home-based monitoring: detecting gait deterioration before it leads to wound formation, and tracking rehabilitation progress objectively. Wikipedia human gait article
Smart Insoles with Pressure Mapping — Sensor-equipped shoe insoles that provide real-time plantar pressure feedback, either to a smartphone app or to the wearer via vibration alerts. When high-pressure zones develop (indicating excessive loading on a vulnerable area), the system alerts the patient to shift weight or adjust footwear. This is the home-use counterpart to clinical pedobarography — continuous monitoring versus one-time assessment. Early warning of developing pressure ulcers before they become open wounds.
BASIL Trials (Bypass versus Angioplasty in Severe Ischaemia of the Leg) — Two landmark clinical trials comparing revascularization strategies for chronic limb-threatening ischemia (CLTI). BASIL-1 (Adam et al., Lancet 2005) found that bypass-surgery-first was associated with better amputation-free survival at 2+ years compared to endovascular-first in patients with suitable vein conduit. BASIL-2 (Bradbury et al., Lancet 2023) found the opposite: endovascular-first revascularization was more cost-effective and associated with similar or better amputation-free survival compared to bypass-surgery-first. Current evidence suggests the optimal strategy depends on patient anatomy, vein availability, and surgical risk. This directly informs treatment decisions for post-clubfoot patients with critical ischemia who need revascularization before reconstruction. PubMed: BASIL-2 trial Bradbury 2023